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tv   Charlie Rose  WHUT  June 22, 2010 11:00pm-12:00am EDT

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>> rose: welcome to our program. tonight, a charlie rose special edition. in the ninth episode of our brain series, we look at the mentally ill brain. >> emile krep lynn in around 1900 revolutionized the field. people had not known whether they were dealing with a number of different illnesses or one major illness and he broke this down into two major categories: disorders of mood and disorders of thought. and disorders of mood he characterized depression and manic-depressive illness and disorders of thought he is characterized schizophrenia which he called dementia praecox. dementia early phase of life. as you outlined, we have a very good understanding for descriptions and later descriptive work of the nature of these diseases. >> rose: the ninth episode of the charlie rose brain series underwritten by the simons foundation coming up.
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captioning sponsored by rose communications from our studios in new york this is charlie rose. >> rose: continue we continue our exploration of the wonders of neuroscience. our subject this evening is mental illness. when our mental processes go awry, the results can be devastating. diseases such as depression,
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bipolar disorder and schizophrenia are some of the toughest known to humankind. they interfere with a patient's thoughts, motivations and even one's sense of self- society has stigmatized mental illness for thousands of years. only recently is we come to think of mental disorders as serious mental conditions. this break through in understanding has improve it had lives of those stricken and opened the door for important research. with proper care, many are treated and able to lead productive and fulfilling lives. tonight we'll meet two remarkable women who have riz on the the top of their field despite suffering from mental illness. kay redfield jamison is an authority on bipolar disorder, a disease she's struggled with throughout her adulthood. she's a professor at johns hopkins university and codirector of johns hopkins mood disorder center. elyn saks was diagnosed with schizophrenia as a young woman. after keeping the disease private for most of her adult
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life she revealed her illness in 2007. she's a professor at the university of southern california gould school of law and founder of the saks institute of mental health law, policy and ethics at use see. also joining me are three scientists who have performed cutting edge research into the biology of mental illness. jeffrey lieberman studied the neurobiology of schizophrenia and related psychotic disorders. he's director of the new york state psychiatric institute. seestephen warren, he helped isolate the gene responsible for fragile x syndrome. he's studying the genetic basis of psychiatric disorders. helen mayberg, her research uses scanning technology to isolate the brain regions involved in clinical depression. she has performed studies that illustrate the positive affects of deep brain stimulation on depressed patients my cohost is dr. eric kandel. he is a nobel laureate, a
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professor at columbia university and a howard hughes medal investigator. i'm pleased t begin this conversation with this sense that for reasons you will tell us, this is a different series. >> here we're speaking about major psychiatric disorders as you outlined, we're going to discuss depression, man i can depress i have dikorder also called bipolar disorder and schizophrenia. what is the biological nature of these disorders and what can we do about them? these are devastating disorders. they affect the way people think, they affect the way people feel. they affect their motivation. moreover, one of the tragic aspects of these disorders is they affect people early in their lives, just as they're beginning to reach the peak of their productivity.
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their peak of ability to enjoy themselves. schizophrenia typically begins in college or the early 20s. although there are vicissitudes in these diseases, often they remain with people for the rest of their life. therefore they're an extremely heavy burden &or e paent and for societatarge. fortuna,ely as yom've@ indi#ate, the--k are ,reatable and@ we now have se clues as to what@ opmiz%s @treatmt. early int%rvtion and combination of psychotherapy and drug therapy. >> rose: once again off book here which is important because we constantly look ahead but at the same time we see the foundations for the kind of studies we make. >> you're absolutely right. this is an extremely important guide. the whole history of psychiatry which is a culmination of emile kraepelin is interesting. we've known about these illnesses since hip pockties, the greek fee seugs in the
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5th century not only spoke about depression and manic-depressive psychosis but specifically indicated these are medical illnesses. but this idea was lost on european medicine for the longest period of time. during the middle ages, even later in the renaissance period, these were thought as demonic disorders. people possessed by the devil or moral degeneral wrists. and people were put abby that insane asylums far removed from the center of town and kept in chains so they don't move around fortunately, this situation was reversed in about 1800. the paris school of medicine began to really express a very modern view of medical science and leap in pin nell, a great french psychiatrist realized psychiatric disorders, as hippocrates said, are medical
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illnesses and he began to institute humane treatment, the beginning of psychotherapy with mental patients. from 1800 to 1900, no progress was made in understanding psychiatric disorders. one couldn't localize them specifically so one didn't know is there one mental illness or are there many? and that's when our mutual hero, emile kraepelin, came on the scene. and his textbooks which began to emerge around 19 and connued til heied in926, he outlined, for example, in this book in his first three chapters he defines the fact that mental illnesses are t unitary, they affect two different processes, they affect mood, emotion on the one hand, and affect thinking on the other. and he defined the disorders that affect mood, depression and manic-depressive disorder and he defined the disorders of thinking as schizophrenia. he called it dementia praecox.
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he thought it was a deterioration of cognitive process in the brain early in life, praecox. and as you outlined, we have some insight into the nature of these diseases. we know that depression is an illness that involves mood, which is associated with the feeling of worthsness and inability to enjoy life. nothing, it's all pervasive. nothing gives one pleasure. and there's a feeling of helplessness, of worthlessness, often leading to thoughts of suicide and, tragically, to suicide attempts themselves. 25% of people that have depression also have manic-depressive illness. they have the opposite end of the spectrum. they feel fantastic at the beginning of the disease. better than they've ever felt in their life but ultimately this leads to grandiosity and frank psychotic episodes. schizophrenia is a thought disorder that has three types of symptoms: positive, negative, and cognitive.
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the positive symptoms are kris i can of schizophrenia. it's the thought disorder, hallucinations, delusions, acting crazy. the negative symptoms are the social withdrawal, the lack of motivation. and the cognitive disorders are the difficulty with organizing ones life and the difficulty with a certain kind of memory, called working memory, short-term memory. fortunately as you indicated we can now see people who have had effective treatment who have very productive lives. and kay jamison and elyn saks, despite the fact they suffered the this disorder much of their life, have rich personal lives, both of them involved in meaningful interpersonal relationships, marriage, that is very satisfying to them and having spectacular academic careers. so there's tremendous hope for the treatment of the disease. i i but this is a remarkable thing. before we've had some of the leading and cutting edge scientists involved in neurology and brain science.
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here we have not only two who are engaged in important research and are leaders in their field but are also suffering, living with. >> this gives such hope to all of us that you can have these devastating diseases and with appropriate therapy you can lead a meaningful, rich life. >> rose: we'll also find out a bit of the genetics in all of this in terms of the genetic basis. are they related biologically? >> well, that's still under act i discussion. we're going to hear from steve warren. we're going to hear from jeff lieberman and helen mayberg, the biological underpinnings of these diseases. and we know that there is some genes that are different, but it's beginning to emerge that some genes are shared by the two diseases. >> rose: all right. this is one of the most interesting things we have done because in addition to the cutting-edge science there's also this extraordinary personal
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testimony. we begin now with our conversation at the table. tell us about depression and bipolar disorder. >> well, i think one of the things that's really interesting about depression and bipolar disorders is that they really affect not only mood but they affect energy and sleep as well. and thinking. so that people can... when they're depressed they can be very obsessive, think often of dying. but the mood is not one so much of sadness as it is really of terrible hopelessness and deadness and disinterest in life. and so all the things that ordinarily are interesting in life to people become irrelevant, basically. and people have trouble sleeping, they have trouble getting to sleep, they have trouble staying asleep. so it's an enormously all-inclusive illness. i mean, people tend to think of depression just as mood but it's really much, much more than that. and bipolar illness is, as eric said, the mania is in many ways
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the opposite. the people very often have enormously high moods, feel better than they've ever felt in their life. so it's often very difficult to convince people that they're man i can that they're sick because they feel great. if you are talking to an 18-year-old who's saying... staying up all night, full of energy, great ideas, seemingly great ideas, thinking fast and furious, you know, not very convincing to tell them they're sick. so that's one of the major clinical problems in treating these illnesses is that they do affect people when they're young and when they're very unlikely to stay in treatment. >> kay, people often speak about psychic pain with depression. do you want to speak a little bit about that? >> one of the things that's hard toast explain to anyone who's not been depressed is how isolating it is, how painful it is. and that kind of pain just, i'm convinced, cannot be put into words. no matter how many great writers have tried to put these things into words, you simply cannot
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convey to anyone... when you think about illnesses like terminal cancer where you would think people would be thinking of dying and committing suicide, the suicide rate is really quite low. the people who really tend to kill themselveses are people when they're depressed. it's a level of agony that is just astonishing. and as i say, isolation, a sense of what's the point? you don't feel human. you don't feel... you can't think, you can't feel, you can't love. >> rose: and some people reach out for suicide. >> absolutely. >> rose: when did you know? >> well, i certainly knew... i first sort of flew quite high, as it were, when i was about 17 and a senior in high school. and i felt great, i felt no pain. i had a wonderful time. but it wasn't that different from my usual joie de vivre. (laughter) so i was noting my friends were dropping like flies from exhaustion. it didn't seem that bad. what then happend is i crashed completely and i had never been
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depressed a day in my life, i never thought absuicide a day in my life or a minute in my life and all of a sudden i was incapable of remembering anything, concentrating, reading anything in school, making sense of anything. and i just wanted to die. and i went around trying to figure out how i could die. i thought of death. i felt... and i knew something was very seriously wrong. but at that time i didn't put it into... nobody talked about depression. nobody talked about bipolar illness or man i can depression. the words weren't there. so i didn't know what to do. so i did nothing. >> rose: until? >> well, i kept on that way up and down up and down for another ten years. and then i went flamingly psychotic. i was ah-ha luce nateing and delusional, man i can. sending a lot of money that i didn't have and not wisely. it was a medical emergency. so i was brought to care, as it were, and i was very fortunate. i had terrific psychiatrists who
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diagnosed what i had absolutely correctly immediately and i responded very well to lithium. >> rose: but so the interesting thing here is you are... in your field one of those suffering. >> yes. yes. there's nothing more motivating in life than nearly dying from an illness-- which i did because i tried... >> rose: because you know a lot about it. >> because you want to know more. you really... you're a little impatient with the pace of the field and it's very motivating. >> rose: elyn, what do we know about the biology? >> well, our approach to the biology of these major mental illnesses came from chemistry. and chemistry has dominated biological research for over 50 years. the major hypothesis with major depression was the biogenic amin hypothesis, sort of a low on serotonin or norepinephrine and
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that really was driven by observations of drugs that would alter those brain neurotrance mitters. and then the recognition that replacing those neurotra *pbz mitters seemed to ely live@symptoms. and that created the foundation for a hypothesis that these were deficits in these brain neurotrans mitters. the problem was is just filling up the tank didn't keep you well and that it really didn't accommodate the course of illness for many people. but it did drive a lot of very, very good neurobiology to understand the important role of serotonin in mood regulation. how it strengthens... >> it was therapeutically helpful for many people. >> and that's the most critical point is despite the fact that it doesn't explain all of the biology, it has changed the lives of so many patients. and as a neurologist, we're interested if not just what chemicals but where the chem contacts act. and like every other neurological disease where, in this one, in the case of
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depression, you have a mood problem combined with slowness of movement, motor changes, a change in cognition, people are slow thinking as well as disorganized but not like we're going to hear about psychosis. as well as a dysregulation of circadian systems. your sleep is off, your libido is off, your appetite is off. these are behaviors that we know a lot about where in the brain they live. and with the advent of neuroimaging it was possible to test those kinds of hypotheses not so much which chemicals but what brain regions are doing what. and with tools like positron ely mission scanning, or functional resonance imaging, we can map the brain in action and know our brain areas we ascribe these behaviors to. are they overactive? underactive? and we can start to map precisely how the brain circuits that mediate this disease are.
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>> helen was very interesting, because she came into the field of psychiatry being a neurologist. and so she was interested in the kinds of things you've been talking about. where is it located? and she was the first person to find a biological marker, an area in the brain that was abnormally active in depressed patients. do you want to discuss that? >> well, again, i mean, we as well as many other investigators using images were really trying to take groups of people who had classical symptoms, not on medicine, and literally see what was wrong with their brains. are areas overactive? underactive? is it one area or another area? and our work started to focus not just on one area, but one area became very much critical. it's an area called the subkohl los sal sing lay. and what we found is that its activity is over active. singulate in people when they're depressed and there's an affect on the frontal lobe, thinking part of the brain that are
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underactive. so there's almost a tug-of-war as the patients describe where there's psychic pain, a very active state of suffering that we think is really driven by this subcollosal sync late. >> this is a fantastic advance because this is the first time one had a good biologic marker and jeff will show us this in schizophrenia as well. but this is the first time someone had an anatomical defect and we'll learn how you can now use this to follow the outcome of treatment. >> rose: tell me about schizophrenia, the clinical syndrome of schizophrenia. >> well, as eric said, schizophrenia is an illness that involves poll 3o -zive the solutions like hallucinations, and cognitive impairment. when i traog to explain to other people what a psychotic episode is like, unlike mania which is fun, a psychotic episode is terrible, it's enormous pain. i say it's like a waking nightmare with all the bizarre images and impossible things happening and the utter, utter terror. w-pbl w a nightmare you sit up in bed and wake up and you can't
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just make psychosis go away. so that's what it feels like. for myself, i will have prominent bizarre delusions like i've killed hundreds of thousands of people with my thoughts. i have occasional hallucination of a big spider walking up a wall. santa claus coming out of a t.v. who knows what that was about. and i also have dig organized thinking. so i had a breakdown on the roof of the yale law school my first semester there and i said to my classmates "are your legal cases being infiltrated? we have to case the joint. i don't believe in joint bus they do hold your body together." so loosely associated words when put together don't make sense. and that happens to me as well. i have been very fortunate that except for the first two years of my illness i have not had negative symptoms. >> rose: now, are there phases for this? >> you know, there are different sort of what are called course indicators. some people might one episode and be fine. some people are chronically psychotic. some people have episodes with interepisode being okay, which is where i fit in.
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and on my own course of my illness i divide it into different phases. in the first phase the kind of prodrome a.m. phase where things ed going wrong i had my first kind of florid psychotic episode. i started walking home from school in the middle of the day and felt like the houses were khaoupb kateing with me. they were sending messages. "you are special, you are especially bad. look, see, you must find." it was very scary. when i got to oxford, i kind of officially broke down and that's the second spear period. it started out looking like depression with mild paranoid features but overtime developed into more of a thought disorder than a mood disorder. and i was hospitalized the first year for a month, the second year for four months. by the second hospitalization i was having really frank psychotic thoughts like beings in the sky were putting thoughts in my head commanding me to do things like walk under... in the hospital tunnels underneath the hospital and hurt myself and things like that. eventually they sent know a psychoanalyst which i think was a prescient idea that it would
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help me because it's been enormously helpful. and during that phase i was not on medication. two things happened. my psychotic symptoms got worse, the positive symptoms got worse. so i was, like, living in the land of psychosis maybe 80% of the time. >> rose: this was during analysis it got worse? >> yes. but the negative symptoms got better. i started being able to relate to people again and work again. and my own theory is through the megaisim in of getting connected with a therapist i started getting connected with other people, too. then i had a big breakdown in new haven, got analysis with another analyst and got on medication and had a big ten-year struggle with whether i needed medication. for me my motto was the less medicine the less defective. and the way i could prove i wasn't really ill was by getting off medication. so i undertook each effort with great gusto and failed miserably eventually i went to los angeles, i got a great teaching job and my analyst started saying, you know, you should just stay on the medication and get on with your life. eventually i tried that. this is the fourth phase.
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got in a great medication, first zyprexa then clozapine. my symptoms haven't gone away completely. my husband says psychosis is like an off/on switch and... not like an off/on switch but a dimmer. so at the far end i'll have a transient thought like i've killed people which i immediately dismissed. further along the continuum i might spend two or three days at the land of psychosis and at the far end i'll be crouching in a corner shaking for two weeks. that hasn't happened in a decade >> rose: you wrote a book called "the center cannot hold." was it hard to be public about this this? >> i had a lot of people who recommended i not do it. including a geriatric psychiatrist, a professor who said "do it under a pseudonym." and i thought that would send the wrong message that this was so awful, awful, you can not say it out loud. >> absolutely. >> the two of you are so articulate about your illness which makes the whole thing so understandable people but you raise an issue i would like both of you to address.
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that is you also made the point that you couldn't stand being on lithium. that your therapist told you "why don't you up the dose of lithium?" and you said "if you like lithium so much, why don't you take it?" (laughter). >> well, this is not too long ago. he suggested i might up my lithium a little bit and i said "if you love it so much, why don't you take it?" he said "you know, kay,'ve been treating you for decades, you haven't changed a bit." (laughter) it is a struggle. i mean, it's not a stug -l for me anymore because i nearly died and i don't struggle. but at the beginning i think for most people the idea of... >> admitting the disease. >> plus there's bad side effects. >> true. >> the side effects are very impairing in your work, in your personal life. >> but i actually think what you point is sort of what we call the narcissistic injury of having an illness and needing medication is hard to come to terms with. i used to say "i don't want to use a crutchn't" now i say if my
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leg were broken of course i use a crutch. shouldn't i treat my neurotransmitters at least as kindly. i've totally changed in how i think about it. >> rose: steve warren, what about president her ready? >> we know genetics plays a role by looking at family histories. so something like schizophrenia occurs in 1% in the normal population but if you have a sibling with schizophrenia then your risk goes up to about 9%. even more striking is if you look at identical twins. they share 100% of their genome and the risk now is nearly 50%. what's important is the it's not 100% like it is with a simple genetic trait like cystic fibrosis where identical twins, both twins, would always have the same disorder. here half are discorps tkapbtd or don't share that disease. that says, then, that there's other factors playing a role like environmental factors. you can see also looking at
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non-add cal twins who are essentially just siblings but yet they have a higher risk than normal siblings because they share more of an environment so we think of complex disease as now having contributions of the genome as well as contributions of the environment. usually it's easier finding the genetic factors first and then trying to sort out of t environment. >> rose: even though there's a lot of genes involved here. >> well, the problem is we know it's not one gene, we don't know how many genes but it's probably a handful of genes.'re learningn the last several years is that the brain, unlike many other organs, presents an enormous... what we call a mutational target. there's so many proteins that contribute to how the brain works that if you disrupt any one of them, you might having a similar outcome. and so the different genes might all lead to the same phenotype so it gets to be kind of a hard thing to narrow down.
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but it's complicated but i think now with the new technologies that have been emerged in the last couple years, sequencing, being able to sequence genomes rather cheaply and other technologies, that at least gives us optimism that we'll be able to identify these genes in the future. >> rose: jeff, take us to the biology of schizophrenia. >> well, charlie, elyn gave a beautiful description of the mental state of schizophrenia and steve has just told us that genes contribute to the risks that develop it. so what it means is that the seeds for the illness schizophrenia are really sewn during early development, in gestation toffee us the and the developing brain and it affects the way not all cells in the brain but a select group of neural circuits, the same kind of circuits that exist in computer chips or stereo equipment come together and function. now, the genes confer a certain degree of risk which environment
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can either increase or it can maybe reduce. so famine or nutritional deficit s during... exposing the fetus during phreg pregnancy may have this affect. exposure toffee us the to infection like during influenza epidemics or toxic exposure if the mother does drugs or happens to have a toxic exposure can amplify this risk. but then during childhood this you will haver inment is pretty much dormant and in individuals who are vulnerable to schizophrenia these neural circuits during adolescence and young adulthood can begin to become dysfunctional. it occurs often times in the context of stress, like when elyn was in school taking final exams, going to college, experiencing recreational drugs, maybe being drafted and going into the military. these stresses cause a dysfunction of these neural circuit which is result in the dysregulation of the chemicals that elyn... that helen was
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referring to but in this case involving dopamine. and this dope tphurpblg i can stimulation becomes excessive and leads to the psychotic symptoms that elyn was experiencing, the hallucinations, the delusions in the brain. now, the neural circuits involving dopamine really have three different pathways. one projects from the brain stem into the temporal lobe. and this leads to the psychosis, the psychotic symptoms. another leads from the brain stem into the frontal cortex and this affects cognitive functioning. and then a third projects to the striatum, and this affects motivation and interest in things. so these three different pathways, when the dopamine becomes dysregulated under stress, during the early... late adolescence early adulthood in life lead to different clinical manifestations which come together to form the illness
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that kraepelin diagnosed. now, right then treatment can stabilize the illness. but all too often people don't come to treatment until after it's... they've been sick for many years and... or they stop their medicine and they get sick again and when this happens and you have repeated insults to the brain, this dysregulated functioning, these neural circuits creating dopamine this leads to a progression. and the progression, like somebody who has multiple little strokes, can lead to some decline in which people are not able to recover to the same level and if you actually take brain scans over time you can see the subtle perceptible loss of brain gray mat cher is reflecting the elimination of these synaptic connections. >> rose: tell me about this, kay, you've experienced this grief and depression. >> i got very interested in grief and depression just because i had both. i certainly had a lot of personal familiarity with
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depression and clinical. but my husband died about five or six... seven or eight years ago and i was struck then by the differences between grief and depression. even though they often get put together in the same category. grief is something that always of us will experience, have already experienced, will experience. and depression is something that a lot of people will but not everyone. and the question is what... why do they exist and how are they different? and so i struggled with that in a book to try to sort those things out. and one of the things is that's most striking about grief is that when you grieve, you feel alive. even though you may be desperately sad and unhappy and missing and mourning. you feel alive. you don't feel unconnected with the world. and, in fact, you can rather easily reconnect with the world if friend come in or you go out
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on engagements. and, in fact, grief comes and goes in very much waves that you... when you least expect it. but it's not an unremitting state and you don't die inside. whereas with depression, depression is unremitting. it doesn't respond to the world around you, to the environment. you could be told the best or worst thing in the world and it doesn't have that much of an impact. it's an internal state. and one of the concerns i have that, along with a lot of my colleagues, of course, is that you don't want to medicalize the human condition. you don't want to start putting people in psychotherapy or giving them medications because they're grieving. i mean, it's human... the human condition and it's part of what we learn. you move on from, you learn about. >> rose: the challenge is to make sure you distinguish between the two? >> that's right. >> yes. and that you recognize when people have... actually the real challenge is to recognize when people have both so that you can treat the depression without people having to go through
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additional horrendous pain. you can treat that which is treatable and then leave to nature that which was nature. >> she wrote a marvelous book called "nothing was the same" when richard died. several years later she wrote this. first of all, richard, her husband, was a fantastic guy, a major psychiatrist and the two of them had a great influence on each other's lives which you describe very beautifully. it was actually sort of a love story, the book. and she just expressed it so beautifully the difference between this grief that comes and goes. it's not all the time. you can be moments of joy you can experience that you can't when you have the depression. >> it's quite interesting because you can actually study intense personal sadness and map it and get a signature of that and you can actually to that same thing in people who are depressed and actually look at the difference between being depressed and situationally sad.
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and there are areas of the brain that are different and what struck me, it was a lightbulb moment more me right now from some of our own data that the part that differs is an area of the frontal cortex that is responsible for the self-connectedness. and in depressed people when they're currently depressed and they get sad, that area of the brain doesn't come on as it does in healthy people who are experiencing a past episode, recollecting a sad event. >> you look at... how society responds to you if you're depressed as opposed to grieving. everyone can reach out to you-- almost everyone-- unless they're complete creeps. but for the most part people will really reach out to you if they know you have undergone a loss like a death. and they will do so. and those rituals were work for a while. not totally but they will work. and society has evolved ways through religion and friendship and so forth to do that. in depression people avoid you because it is... first of all,
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depression is contagious, the mood is contagiousment and secondly they have a real sense that they can't connect. they can not make a connection with you, you can not makes a connection with them. >> one of the interesting things that emerges with both of you is that you had treatment fairly early in your disease that was a very interesting combination of treatments and very effective in both of your cases. i wonder whether you could say something about that. >> well, elyn and i have talked about this a lot. i'm a huge admirer of everything she's done and her writing and one of the things that we've talked about is that it's not just medication. i mean, i'm completely behold on the medication. i would be dead as a dead duck without it, i don't have any question about that and i believe in it scientifically, personally, whatever. but psychotherapy has been life saving. and we both have been fortunate-- certainly i speak for myself-- to have tremendously good psychiatrists who did not make the distinction
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between psychopharmacology and putting it over here and psychotherapy over here. he did both. and he did it both with ease and grace and tremendous skill. knew an enormous amount about the illness and an enormous amount about human condition and human nature and it's tremendously important. >> but what is so beautiful about this is one tended to think of psychotherapy and drugs as working in very different ways. one is talk therapy and the other is biological. and now it's clear that from helen's studies and other people's studies that psychotherapy works on the brain. it's a biological treatment. >> rose: wait, okay. so psychotherapy produces a biological change? >> change in the brain. it's like a biological treatment. when you and i are having a conversation, it changes our brain. it's a biological interaction. >> the important thing to keep in mind is when you're talking about mood disorder, bipolar disorder, depression and schizophrenia, we're talking about a pathologic condition
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that medication helps to restore the neurochemical balance but that in addition the value of psychotherapy-- and i'm going to say something that's a little bit provocative-- it's the therapy but it's also fundamentally the con sis tense supportive and healthy relationship with the individual giving you the psychotherapy. >> absolutely. absolutely. absolutely. these are the key ingredients to basically turning around mental illness and making people achieve what kay and elyn have as opposed to living a life of despair and inability to be productive. >> rose: go ahead. >> i was given a grave prognosis. i was expected to be able to live independently let alone to work. i think if i just had medication that would have happened if i had just had psychotherapy that would have happened. a lot of people think psychodynamic therapy isn't optimal for people with schizophrenia but i think it
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helps them, including me. >> i think we've appreciated for some time in jeff's department that psychotherapy and drugs go together. elyn's case is very uninitial the sense that there are very few people with schizophrenia who availed themselves of psychoanalysis. so this is very rare. and you actually describe very nicely in your book and some of your talks that insight actually helped you. >> there are a bunch of things if i might run through them. so i think first of all stress is bad for all illnesses, and particular mental illness and psychotherapy helps you identify and cope with or avoid stressors. second, it helps you develop more psychological mindedness and a stronger observing ego so you can take a step back and observe what's going on in your mind. third-- and i this is this is important-- it helps you come to terms with the blow to your self-esteem and having a mental illness and accepting it. it's a place where you can bring your chaotic destructive thoughts and say them outloud. >> that's what therapy is about. beautifully said. >> rose: and know you're not alone. >> that's right. >> the reality also is that our
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current reimbursement system, how we pay for mental health care, does not support what you're hearing is optimal treatment. >> we have been fortunate in being able to pay. >> having the resources to do this. >> and it's the standard of care by anybody's study of the studies. that psychotherapy and medication is better than either one alone. but the reimbursement system is such... >> rose: wait. reimbursement system, are we talking about insurance companies are not recognizing this? >> insurance, medicaid and medicare. >> medicare, too? >> kay and elyn had the resources and the families and the intelligence to know how to seek the best treatment. but standard payment for health care, if it's not out of pocket, does not pay for these services. >> despite the fact... >> rose: what's their rationale? what do they say is the reason? >> it's cost containment. >> although it's short sighted in the sense that the... one of the other major reasons for psychotherapy is effect...
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effectiveness is it doesn't do you any good to have effective medications if people don't take them. and the major clinical problem in treating bipolar illness is not that we don't have medication, it's a that people won't take them. >> schizophrenia, too. >> schizophrenia as well. people don't like to be on drugs for a mental illness. >> and for a lot of reasons good and bad. and so psychotherapy helps with that. >> it helps... >> rose: psychotherapy helps keep you on your drugs? >> the physician makes sure you take it. and i think there's another point. there is... this is not an area i'm extphert, jeff, so correct me if i'm wrong. there is a bias toward mental illness that still persists to a certain degree. and this is really reflected in the reimbursement. >> rose: yes. >> but things have gotten bet we are the parity bill. u.s.c. which is covered by federal law because we're self-insured is very generous with mental health care and i'm getting quite a bit of my psychoanalysis paid for so it's bet we are many people. >> it's important to recognize social policies are self-defeating because although health care expenditures are a huge concern to the economy, we
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don't support the services that we know will reduce the morbidity and illness and cost to society. >> it's an enormousable if burden, mental illness. and one of the reasons this is such an historic occasion, to see people with serious illnesses who, when appropriately treated, have a fantastic life and contribute importantly to society. >> we could haven't done it without... >> they are not the typical face of people you think of for mental illness. >> not at all. >> you think of the psychotic killer or the deranged individual, not productive individuals who have successful careers. >> rose: under what circumstances do psychotherapy and medication fail? >> it's a fact that it's very clear that despite fact that there are many, many medications that can work in individuals and a number of evidence-based psychotherapies, some people don't get better with any combination of anything that we've got. the good news is that the best treatment for depression that we've had for a very long time is electroconvulsive therapy and that can get people out of an
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episode of depression where they may be suicidal and moribund. on the other hand, the more medications you fail, the less likely that e. c.t. will keep you well and it has side effects. so we here in a situation that we have people that are suffering in the way we've heard described that there is nothing we can do and they are in... it's a malignant situation. >> but you went beyond this. >> well, we took a different tack. we said, look, we're identifying a circuit in the brain that seems to go wrong with people when they're depressed. we see that we can correct the circuit function with medication, we can correct the circuit function with cognitive therapy, we can even see its correction with placebo when people recover. and we started to isolate that certain changes needed to happen or you didn't get well. what we did is we were in the right place at the right time. the work by the neurologists and the neurosurgeons on parkinson's recognizing that when people stop responding to the
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medications for parkinson's disease that by knowing the circuits of parkinson's disease they could target in the circuit directly with focused brain stimulation called deep brain stimulation where an electrode is placed precisely in the brain by a skilled neurosurgeon and that you could literally tune the abnormal circuit exactly where you knew it was dysfunctional. so we had a hypothesis that we knew the circuit for depression and that we would go directly at the subcollosal cingulate and we would say we want everything that talks to that brain region to be affected and we literally implanted in people who basically everyone had given up on we targeted that area, turned the electricity on, and saw some incredible things in the operating room. but more importantly, turned down this region, area 25 and actually had these people
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recover who had been in this purgatory... >> rose: it's an immediate clearing of the mind? >> immediate. >> well, to make this point is recovery from depression takes time. this is very important to take away from this. but in the operating room, it's like we were watching the depression... >> waking up. >> rose: waking up. it was not that they had an immediate antidepressants affect, but that the psychic pain... >> they felt differently. >> they felt differently. something about the illness had been fundamentally changed by that acute stimulation. but it required continuous stimulation over time to actually maintain the affects. because if you turn it over, over several weeks with stress you will go back to the state you are in. with but it tested the idea that you could tune the circuit directly with electricity. >> rose: does this work in schizophrenia? does it have possibilities in schizophrenia? >> it absolutely has possibilities. i mean, psychiatry utilizes three modalities of treatment.
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talk therapies, medication, and brain stimulation therapy. the most common form of brain stimulation historically was shock therapy which suffered the a bad reputation which is very undeserved because it's highly effective if safely administered. helen has pioneered a technique developed for parkinson's disease where you have a single lesion, a specific anatomic focus that you can say this is where the pathology is and you then attack it with electrodes. in schizophrenia, we have three different circuits that are dysfunctional. so we have to decide exactly where the electrodes should go and we're not quite there yet. the. >> the work that you've done and our understanding of depression makes one think that you don't have loss of synapses and nerve cells because there are periods in which people can function very well. with schizophrenia, if the disease persists for some time, there is very good evidence-- and jeff's work, some other people's work-- you lose snap i can connections. what is critical in
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schizophrenia is what ellen benefited from. early intervention. it's true for all psychiatric illnesses. the earlier you can diagnose it. one thing that happens that people who have the disease, the patients, like to deceive themselves as both of you did. >> for way too long. >> and the families like to deceive themselves. so you remove the stigmata. if you had chest pain, your parents would not say "let's wait a few days and see what this is about." they would take you immediately. >> or it's just a pain. >> right. >> rose: what do you think, steve? >> i think what eric just said is important from the genetic contributions. what we'd like to do is been b able to identify the genes that would predispose an individual to these disorders prior to on set. so then they can be perhaps more responsive to therapeutics and prevent the on set of... >> rose: and how are we going on that? >> well, we're coming along. i think the idea is to identify a few genes that play a big role and that gives us a toe hold
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into the biochemistry of what's going on in the brain. it's just like helen said. there's a lot of circuits and pathways where the genes are contributing. so it's a highway with every gene is the stoplight or the stop sign and each individual gene can be changed. but it has the same affect on how the traffic flows. and that's part of the difficulty in identifying these genes is it's so complex. if you look at the synapse alone, there are hundreds and hundreds of pro proteins that interact. >> so in everything we're talking about here in terms of depression and disorder and schizophrenia, we're all talking about treatment so far. where is cure? >> cure is really not immediately on the horizon. but the illnesses, if they're identified promptly and treated effectively, can be stopped in their tracks. so we're talking about remission, which is within our
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grasp if we simply get our act in order in terms of cure, cure will depend on the identification of the genes and the ability to preempt the illness prior to the on set. >> rose: prevention. prevention. >> absolutely. but there's an important thing, charlie, to realize. and that is many illnesses are like this. there is no cure for diabetes. it's a life long illness. hypertension. there are doesens of diseases that you can name. in fact, most of the common diseases it's a question of good therapy and then maintaining that therapy with watchful waiting. and we see two spectacularly rich lives here of people who still suffer from the disease but it's under very good control. so i think what has to... one has to come to grips with the fact that for a long time we will not be able to have cures but that doesn't mean one doesn't have essentially the effective cures. that is people living with the disease, struggling periodically
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but most of the time being able to lead a rich life. >> i want to make one point also that i think with kay and me it's not just that we're successful occupationally but we have rich friendships. i have a husband who's amazing. you have a fee i don't fiance ws amazing. >> one final point worth emphasizing in this discussion is these are terribly complicated illnesses. this is much more complicated than hypertension or diabetes. these are probably the most complicated illness in all of medicine. >> rose: because? >> because it involves the brain and not just the brain the way it is involved in parkinson's disease, a.l.s., it involve it is highest, most complex functions of the brain. >> rose: what is the question you most want the answer to? >> well, personally i want the answer to how it is that depression is mediated in the brain. what really is the source of the abnormality? we know that gene, environment, chemistry, circuits. but we're not really getting at the fundamental source of what
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makes negative mood progress into a state of absolute other suffering where you can't hold on to any one else to pull you out of the pit. that's the driving force for me. >> rose: you've heard me ask this before. >> well, and same answer, too, probably. to go from a gene to behavior and understand all the steps in between is just... would be fantastic. particularly something as come phrepbgs as a psychiatric disease. >> rose: and how far away are we from that? >> a long way to get there. >> rose: i think... >> the question i would prioritize is not so much a scientific one as a social one. how can we eliminate stigma? i think greatest barrier to making gains at a research level as well as a treatment level is making society accept mental illness as genuine illnesses that require equal treatment to other medical illnesses. >> i've always been interested in the overlap and distinctions
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between normal mood states and cognitive states, intellectual states, temperament and pathology. because in mood disorders, they are very interesting similarities and dissimilarities between... in terms of what's the difference between somebody who is very high voltage enthusiastic spwaoub rant high fire high energy person and someone who goes on to get just the next step over in terms of not man i can but enough that it's getting disconcerting and out of control. and why do these things exist and what is it about human temperament that is o so adaptive about having so many wide varieties of temperament that a certain number of them that fail or get problematic. of... i guess trying to keep these conditions within the human condition in some sense of trying to understand them. >> i mean the easy answer is i'd like to find a cause and cure of schizophrenia. but that's a long-term project
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and sort of more doable things are three: one, studying which psychosocial interventions are helpful for which people with schizophrenia and bipolar illness. some may benefit from cognitive behavioral, so from psychodynamic. you don't have the equivalent of a drug company funding these studies so it's hard to do them and harder to do them for lots of reason. that's one thing. second, i i would like to find t ways to use less force with psychiatric patients. i was really traumatized by being in hra *erpl restraints. anywhere from five to 20 hours a day for several weeks. very, very painful. caused a lot... >> rose: tieing you down? >> yes, a four to six point restraint. and the third thing is the stigma point. understanding why and how to combat it. the final thing is not so much something we should know but something we should do which is provide the resources so that we step up to the plate and give people the abilities to lead full and productive lives. >> rose: what a remarkable panel. what a remarkable story.
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so looking athose episode 10. in this program we've discussed psychiatric illnesses. in the next program we'll consider neurological illnesses and there's been spectacular progress in treating certain kinds of neurological illness. parkinson's disease, even stroke, completely new ways of thinking about strokes. moreover, we'll have a chance to discuss what is the difference between psychiatric disorders between psychiatric disorders these are both brain disorders but one of the interesting things is that even though there's some overlap one feature about psychiatric disortd oars is they often reflect extensions of normal behavior so depression is an extension of sadness. main you is an extension of the euphoria we feel after a very good program and even schizophrenia, the delusions and hallucinations one occasionally
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has in dreams, in nightmares. so a lot of psychiatric symptomology are extensions of the normal. this is one of the thins freud emphasized. neurological diseases, fragment behavior and often bring out completely surprising features of behavior. for example, there is with certain kinds of strokes symptom of neglect in which a patient will completely ignore an arm or leg they have because it's paralyzed and they will sometimes push it out of bed saying "this does not belong to me." so we will not only learn about the localization of function but we will see how abnormal functions appear and normal function is fragmented. >> rose: episode 10 next month. see you then. captioning sponsored by rose communications
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captioned by media access group at wgbh
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